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The authors review the past and current challenges in psychotherapy training, research, and practice and the state of psychotherapy in the context of current training and funding, the COVID-19 pandemic, and the current era's pursuit of novelty. Where does the field stand, and where should it go?

The 2020 COVID-19 pandemic has abruptly overwhelmed normal life. Beyond the fear and fatality of the virus itself comes a likely wave of psychiatric disorders. Simultaneously, social distancing has changed overnight how psychiatrists and other mental health professionals must treat patients. Telepsychotherapy, until now a promising but niche treatment, has suddenly become treatment as usual. This article briefly reviews the limited clinical evidence supporting different modes of telepsychotherapy, then focuses on how remote therapy affects clinicians and their patients.

Safety behaviors (SBs) are generally perceived as ‘dysfunctional’ emotion-regulation strategies that reduce physical symptoms and prevent unrealistic feared consequences of panic attacks. However, it is unclear whether all types of SBs are a hindrance or whether some may promote self-regulation in treatment. We propose that the type of SBs might explain some of the variability between panic disorder (PD) patients, and might help to predict why treatment is more successful for some than for others. In this secondary analysis of a subsample of 65 PD patients who received Cognitive Behavioral Therapy in a two-site randomized controlled trial, we examined the associations between type of SB and pre-treatment characteristics and their predictive value on trajectories of change in treatment process and outcome (panic symptoms, interpersonal problems, alliance). An observer-rating system for five types of SBs (avoidance/distraction/control-function and object/people-focus) was developed and applied to videotaped early treatment sessions, with high reliability. Patients with higher levels of people-focused SBs reported higher levels of panic symptoms pre-treatment at both treatment sites. These people-focused SBs predicted poorer treatment response on panic symptoms at one of two sites. Avoidance, control, or distraction-function and object-focused SBs were not associated with treatment process or outcomes. People-focused SBs may worsen PD symptoms, and possibly slow treatment progress, although this latter finding was not consistent across sites. This study differentiated between types of SBs and identified people-focused SBs as possible predictor of symptom change in CBT for PD—potentially relevant for efforts to improve treatment response.

After briefly reviewing the psychoanalytic view of mental life, including the influence of the unconscious on mental life and symptoms, this chapter describes the impact of trauma from the psychodynamic viewpoint. Disruptions in narrative coherence, repetition and re-experiencing, intrapsychic conflicts, dissociation, defenses, intense negative affects, and disruptions in trust that result from trauma are described. Clinical examples are presented to illuminate these factors. In addition, the relevance of the patient’s pretrauma history, their attachment style and mentalization skills, and the specific nature of traumatic experience on the impact of trauma and associated symptoms is elaborated.

This chapter provides descriptions and clinical examples to illustrate core psychodynamic techniques as they are adapted to the work of trauma-focused psychodynamic psychotherapy (TFPP): clarification, confrontation, interpretations, and utilization of patient dreams. Clarification aids the patient in gaining distance and objectivity. Confrontation is designed to help patients recognize contradictory thoughts and feelings. Interpretations tie observed behaviors or thought patterns to the emotional dynamic factors that may give rise to them. Because a core symptom of post-traumatic stress disorder (PTSD) involves re-experiencing traumas through dreams, a focus on the approach to dreams is particularly relevant in this population, and TFPP is the only operationalized psychotherapy for PTSD that makes active use of dreams to gain an understanding of emotional causes of distress. The chapter also illustrates the use of the transference and its interpretation and describes common countertransference constellations that arise. Due to the nature of the impact of trauma, transference and countertransference reactions can be particularly intense and ways that the therapist can effectively use these reactions to guide the treatment are discussed.

Introduction: Panic disorder patients who drop out of treatment typically do not remit from their disorder. How patient-level moderators influence dropping out of one panic-focused treatment over another has never been examined, nor in non-CBT treatments. Method: 200 patients with panic disorder with or without agoraphobia were randomized to receive cognitive-behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), or applied relaxation training (ART) across two sites. Therapy was twice a week for 12 weeks. A two-step variable search method was applied to identify potential prognostic predictors and moderators of patient dropout. Survival models predicting hazard of session-by-session dropout tested the resulting variables. Results: Across treatments, unemployment and higher psychosocial disability on the Sheehan Disability Scale predicted increased risk of dropout, while patients with higher anxiety sensitivity were more likely to complete treatment. Patients who reported experiencing childhood abuse had heightened dropout in ART, but not CBT or PFPP. Men were especially likely to complete PFPP. Session 2 expectancies and patient-rated alliance predicted lower dropout only in CBT. Conclusions: Patient-level factors may influence both whether patients will complete any treatment, and whether they continue in a particular panic-focused therapy. Moderators of dropout (e.g., abuse history) may inform treatment decisions for specific patients.Trial registration: ClinicalTrials.gov identifier: NCT00353470.

The authors describe a psychodynamic psychotherapeutic approach to posttraumatic stress disorder (PTSD), trauma-focused psychodynamic psychotherapy. This psychotherapy addresses disruptions in narrative coherence and affective dysregulation by exploring the psychological meanings of symptoms and their relation to traumatic events. The therapist works to identify intrapsychic conflicts, intense negative affects, and defense mechanisms related to the PTSD syndrome using a psychodynamic formulation that provides a framework for intervention. The transference provides a forum for patients to address feelings of mistrust, difficulties with authority, fears of abuse, angry and guilty feelings, and fantasies.

Objective: This study examines whether, in panic-focused psychodynamic psychotherapy (PFPP), interpretations of conflicts that underlie anxiety (panic-focused or PF-interpretations) are specifically associated with subsequent panic disorder (PD) symptom improvement, over and above the provision of non-symptom-focused interpretations. Method: Technique use in Sessions 2 and 10 of a 24-session PFPP protocol was assessed for the 65 patients with complete outcome data randomized to PFPP in a two-site trial of psychotherapies for PD. Sessions were rated in 15-min segments for therapists’ use of PF-interpretations, non-PF-interpretations, and PF-clarifications. Robust regressions were conducted to examine the relationship between these interventions and symptom change subsequent to the sampled session. Interpersonal problems were examined as a moderator of the relationship of PF-interpretations to symptom change. Results: At Session 10, but not at Session 2, patients who received a higher degree of PF-i...

Mentalization-how people understand their own minds and those of others-is an attachment-based, normative, cognitive, and affective capacity important to interpersonal relations and to certain kinds of psychotherapy. Mentalization seems related to aspects of, and may hold important implications for, interpersonal psychotherapy (IPT). Weissman and colleagues' IPT manual does not explicitly describe improvement in mentalization as a targeted outcome of therapy, but IPT may utilize mentalization as an underlying process. Recent theory emphasizes the applicability of a mentalization model to many, if not all, types of psychotherapy and suggests particular value for affect-focused and socially focused psychotherapies such as IPT, despite IPT's differences in focus and diagnostic targets from mentalization-based treatments. This article reviews the overlap of these approaches and suggests the potential of mentalization to mediate IPT outcomes. ispartof: AMERICAN JOURNAL OF PSYCHOTHERAPY vol:72 issue:4 pages:95-100 ispartof: location:United States status: published

OBJECTIVE: To examine whether working alliance quality and use of techniques predict improvement in Panic-Specific Reflection Function (PSRF), and misinterpretation of bodily sensations in treatments for panic disorder. METHOD: A sample of 161 patients received either CBT or PFPP (Panic-focused Psychodynamic therapy) within a larger RCT (Milrod et al., 2016). Data were collected on patient-reported working alliance, misinterpretations, PSRF, observer-coded use of techniques, and interviewer-rated panic severity. Random-Intercept Cross-Lagged Panel Models assessed bi-directional associations, disentangling within- and between-patient effects, and accounting for prior change. RESULTS: Higher alliance predicted subsequent within-patient improvement in PSRF in PFPP, but worsening in CBT. In both treatments, focus on interpersonal relationships predicted PRSF improvement (with stronger effects in CBT), while focus on thoughts and behaviors predicted worsening in PSRF. In CBT only, early focus on affect and moment-to-moment experience predicted reduced misinterpretation, while high focus on thoughts and cognitions predicted subsequent increase in misinterpretation. CONCLUSION: The quality of the alliance has differential effects on PSRF in distinct treatments. Interpersonal, rather than cognitive or behavioral focus, even when delivered differently within distinct treatments with high adherence, could facilitate improvement in PSRF. Additionally, early focus on affect and moment-to-moment experiences in CBT could reduce misinterpretations.

This article aims to articulate the use of trauma-focused psychodynamic psychotherapy (TFPP) for a 33-year-old U.S. Army veteran with posttraumatic stress disorder (PTSD) in a Veterans Affairs (VA) setting.The patient was treated with TFPP, a manualized brief psychotherapy provided as part of a pilot study. TFPP differs from traditional dynamic psychotherapies in its focus on symptoms of trauma and associated dynamics. The patient was seen for an initial 60-minute intake session and then for 16 50-minute sessions over 5.5 months at a VA medical center.Follow-up three months after termination of therapy indicated that the patient's panic disorder and PTSD symptoms remained much improved, although some rumination and difficulty focusing persisted.TFPP appears promising as shown with this patient and others in VA settings who have been treated with TFPP.

Child and adolescent anxiety psychodynamic psychotherapy (CAPP) is a new, manualized, tested, 24-session psychotherapy articulating psychodynamic treatment for youths with anxiety disorders. The book describes how clinicians intervene by collaboratively identifying the meanings of anxiety symptoms and maladaptive behaviors and communicating the emotional meanings of these symptoms to the child. The treatment is conducted from a developmental perspective, and the book contains clinical examples of how to approach youth of varying ages. The authors demonstrate that CAPP can help children and adolescents: • Reduce anxiety symptoms by developing an understanding of the emotional meanings of symptoms • Enhance the skill of reflection and self-observation of one’s own and others’ feelings and motivations (improvement in symptom-specific reflective functioning) • Diminish use of avoidance, dependence, and rigidity by recognizing how underlying emotions (e.g., guilt, shame, anger), as well as conflicted wishes can be tolerated and understood • Understand fantasies and personal emotional significance surrounding the anxiety symptoms to reduce symptoms’ magical, compelling qualities and impact on the child The manual provides a description of psychodynamic treatment principles and techniques and offers a guide to the opening, middle, and termination phases of this psychotherapy. The book contains chapters on the historical background of child psychodynamic psychotherapy, on developmental aspects of child psychotherapy, and on the nature of parent involvement in the treatment. This manual is intended to be used by clinicians from diverse therapy backgrounds, and it will appeal to the student reader as well as to the experienced clinician.

Child and adolescent anxiety psychodynamic psychotherapy (CAPP) follows psychoanalytic principles by addressing the unconscious meaning of the child’s symptoms, while employing a time-limited, twice-weekly frame, which affects technique. In Chapter 2, the authors illustrate how the therapist establishes a collaborative and empathic relationship with the child, identifies a central psychological dynamism early, and consistently refocuses on the presenting anxiety symptoms and the jointly identified psychological dynamisms. The authors describe variations in psychotherapeutic technique necessitated by the age-related capacities of the young patient. Important psychodynamic principles, such as transference, are described. Reflective functioning, which is the capacity to be reflective about one’s own mind and to envision mental states in others, is explained. Selective attention is paid to symptom-specific reflective functioning, which refers to the capacity to reflect on the specific anxiety symptoms and their meanings as an important mediator of change.

Chapter 5 focuses on the nature and meaning of parent involvement in child and adolescent anxiety psychodynamic psychotherapy (CAPP). Most of CAPP is conducted with the therapist and child or teen alone. The importance of parent participation relates to the practical and natural developmental dependence of the child on the parent, as well as the importance of a solid therapeutic alliance with the parents, which is essential to sustain and maintain the treatment of the youngster. Separation anxious parents are sometimes conflicted about letting go of the child and allowing a relationship to develop with the therapist that largely excludes the parent. It is important for the therapist to be aware of such tendencies in parents so that they can be addressed when they occur and will not interfere with treatment. Specific guidelines are described regarding working with younger children and working with parents of teens.

Objective The contributions of disorder severity, comorbidity and interpersonal variables to therapists' adherence to a cognitive–behavioural treatment (CBT) manual were tested. Method Thirty-eight patients received panic control therapy (PCT) for panic disorder. Trained observers watching videotapes of the sixth session of a 24-session protocol rated therapists' adherence to PCT and their use of interventions from outside the CBT model. Different observers rated patients' behavioural resistance to therapy in the same session using the client resistance code. Interview measures obtained before treatment included the Panic Disorder Severity Scale, the anxiety disorders interview schedule for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the structured clinical interview for DSM-IV, Axis II. Questionnaire measures were the anxiety sensitivity index at intake, and, at session 2, the therapist and client versions of the working alliance inventory—short form. Results The higher the patients' resistance and the more Axis II traits a patient had, the less adherent the therapist. Moreover, the more resistant the client, the more therapists resorted to interventions from outside the CBT model. Stronger therapist and patient alliance was also generally related to better adherence, but these results were somewhat inconsistent across therapists. Pretreatment disorder severity and comorbidity were not related to adherence. Conclusions Interpersonal variables, particularly behavioural resistance to therapy, are related to therapists' ability to adhere to a treatment manual and to their use of interventions from outside of the CBT model. Copyright © 2015 John Wiley & Sons, Ltd. Key Practitioner message Patients' behavioural resistance to therapy may make it more difficult for cognitive–behavioural clinicians to adhere to a structured treatment protocol and more likely for them to borrow interventions from outside the CBT model. Patients' Axis II traits may make adherence to treatment CBT protocol more difficult, although whether this is true varies across therapists. Therapists' adherence to a structured protocol and borrowing from outside of the CBT model do not appear to be affected by disorder severity or Axis I comorbidity.

Introduction When a patient does not benefi t or has intolerable sideeff ects from an antidepressant or anxiolytic medication, the prescribing psychiatrist can rely on a range of evidence-based guideposts. Most clinicians probably feel familiar and comfortable with switching or augmenting medications and with the idea of sequential medication treatment algorithms. As Michael Thase noted in a JAMA Psychiatry editorial, the same does not hold for psychotherapies—although it should. Ignorance of whether or how to change psychotherapies is a major and persisting gap in psychiatric knowledge. We discuss this problem from clinical and research perspectives.

An open, pilot clinical trial of Child and Adolescent Anxiety Psychodynamic Psychotherapy (CAPP), a 24-session, 12-week, manualized psychodynamic psychotherapy, was conducted in 10 patients, ages 8...

Objective: To determine the effectiveness of manualized panic-focused psychodynamic psychotherapy (PFPP) in routine care in Germany. Method: German psychoanalysts were trained according to the PFPP manual. Fifty-four consecutive outpatients with panic disorder (with or without agoraphobia) were randomly assigned in a 2:1 ratio to PFPP or cognitive-behavioural therapy (CBT) plus exposure therapy. Subjects (female 57.4%; mean age 36.2 years) had high rates of psychiatric (68.5%) and somatic (64.8%) comorbidity, and previous psychiatric treatments (57.4%). Assessments were performed pre- and posttreatment and at 6-month follow-up. The primary outcome measure was the Panic Disorder Severity Scale. Results: Both treatments were highly effective. In patients randomized to PFPP, remission was achieved in 44.4% at termination and by 50% at follow-up (CBT 61.1 % and 55.6%, respectively). No significant differences were found. Emotional awareness, a posited moderator of good outcome in psychotherapies, was significantly higher in the CBT group at baseline. It was found to be a strong moderator of treatment effectiveness in both treatments. After adjusting for initial Levels of Emotional Awareness Scale (LEAS) scores, effect sizes (ESs) for the primary outcome were Cohen d = 1.28, from pre- to posttreatment, and d = 1.03, from pretreatment to follow-up, for PFPP, and d = 1.81 and 1.28 for CBT, respectively. Conclusions: PFPP was implemented effectively into clinical practice by psychoanalysts in the community in a sample with severe mental illness with large ESs. Assessment of LEAS may facilitate the identification of patients suitable for short-term psychotherapy. (Clinical Trial Registration Number: German Clinical Trials Register, DRKS00000245; Universal Trial Number, U1111-1112-4245)

This article presents information on child and adolescent psychodynamic psychotherapy (CAPP). Following a definition of anxiety, the authors present study outcomes of nonpsychodynamic treatment approaches, alone and in combination with psychopharmacologic treatment, then explore psychodynamic approaches. A detailed overview of psychodynamic psychotherapy is presented, along with 2 cases illustrating the use of CAPP in young patients with anxiety. Also presented are tables and boxes summarizing CAPP therapeutic processes and strategies as intervention for anxious youth.

Panic-focused psychodynamic psychotherapy (PFPP) is a 24-session, twice-weekly (12 weeks), manualized psychoanalytic psychotherapy with demonstrated preliminary efficacy for panic disorder (PD).1,2 Given the substantial morbidity and the health care utilization of the PD population,3,4 coupled with the sizable proportion of such patients who do not respond (or respond inadequately) to alternate treatments (cognitive-behavioral therapy [CBT] and drug therapy),5–7 PFPP may offer clinicians an additional tool for their therapeutic armamentarium. It may also facilitate a rapprochement between academic psychiatry and psychodynamic perspectives, and a reassessment of the role of psychodynamic therapy as part of the educational experience of residents in training—an experience that has diminished over two decades.

will diminish, lose toxicity; you can verbalize them, understand them, integrate them, gain control over them, even use them to understand and change your life situation (4). Meeting strong negative affect with empathy and without retreat is an active intervention crucial to treating the grief of complicated bereavement (5), the anxiety that habituation requires in exposure (6), the anger of the patient with borderline personality (7, 8) or bipolar disorder, and the acute anxiety in panic disorder. Sharing negative affect with a patient in effect demonstrates empathy. Conversely, to change the subject when emotion becomes uncomfortably intense tacitly conveys that the patient’s feelings are in fact dangerous and best avoided.

Although the need for psychoanalytic research is increasingly acknowledged, many psychoanalysts remain resistant to the performance and findings of this research. Objections to research include a continuing mistrust of research tools and approaches, combined with a belief in the effectiveness of psychoanalytic treatments based on clinical lore and individual experience. Furthermore, as psychoanalytic literature continues to function within its own separate domain, even well-read psychoanalysts can be sequestered from central scientific conversations occurring in the larger literature about mental health. In part due to these factors, few adequate studies of psychoanalytic treatment approaches have been performed. The lack of efficacy research has added to the marginalization of psychoanalytic treatments. Fortunately, in recent years groups of clinicians and researchers have begun to study psychoanalytic treatments, particularly approaches to specific disorders. In this context, this issue provides a welco...

Systematic research on psychoanalytic treatments has been limited by several factors, including a belief that clinical experience can demonstrate the effectiveness of psychoanalysis, rendering systematic research unnecessary, the view that psychoanalytic research would be difficult or impossible to accomplish, and a concern that research would distort the treatment being delivered. In recent years, however, many psychoanalysts have recognized the necessity of research in order to obtain a more balanced assessment of the role of psychodynamic psychotherapy and psychoanalysis in a contemporary treatment armamentarium, as well as to allow appropriate evaluation and potentially greater acceptance by the broader mental health and medical communities. In this context, studies were conducted of a psychodynamic treatment, Panic-Focused Psychodynamic Psychotherapy (PFPP), initially in an open trial and then in a randomized controlled trial (RCT) in comparison with a less active treatment, Applied Relaxation Training (ART; Cerny et al. 1984), for adults with primary DSM-IV panic disorder. The results of the RCT demonstrated the efficacy of PFPP in treating panic disorder, and also demonstrated that a psychoanalytic treatment can be systematically evaluated in a mode consistent with the principles of evidence-based medicine. Two specific features of the methodology, the development of the treatment manual and the operationalization of the adherence instrument, both core building blocks of contemporary psychotherapy outcome research, and their implications for psychoanalytic research are discussed in greater depth. The theoretical, clinical, and educational implications of the PFPP studies are elaborated, and suggestions are made for pursuing further outcome research of psychoanalytic treatments.

Background: Little research has addressed moderators of treatment outcome for anxiety disorders, and none has considered interpersonal loss as a predictor of outcome. Purpose: To examine the effect of interpersonal loss events within the 6 weeks preceding panic disorder onset as a moderator of outcome in a randomized controlled trial of Panic-Focused Psychodynamic Therapy (PFPP) and Applied Relaxation Therapy (ART). Researchers hypothesized that such loss events would predict better outcome in PFPP but would not affect ART outcome. Method: Forty-nine subjects with panic disorder were randomly assigned to a 12-week course of PFPP or ART. Independent raters blinded to treatment condition and study hypotheses rated subjects on the Panic Disorder Severity Scale (PDSS) and Sheehan Disability Scale. Exploratory analyses assessed between-group effect size for PFPP and ART following standard moderator analytic procedures. The trial was conducted between February 2000 and January 2005. Results: Three quarters of subjects reported a narrowly defined interpersonal loss (LOSS) in the 6 weeks preceding panic disorder onset. These subjects had a mean (SD) duration of panic disorder of 8.2 (9.5) years. PFPP was more efficacious than ART, but LOSS did not moderate PFPP outcome. An unexpected finding was that LOSS moderated ART outcome: subjects without LOSS showed no response to ART (PDSS mean (SD) change score = 0.00 [2.90]), whereas LOSS had a pre-post mean (SD) change score of 4.29 (5.60). Neither examination of potential confounding variables nor sensitivity analyses of assumptions regarding attrition altered these findings. Conclusions: Interpersonal loss events preceding onset of panic disorder were more common even than in prior studies. These losses moderated outcome in ART, a therapy that does not focus on such losses. Implications and the need for future research before incorporating these findings into clinical practice are discussed. Trial Registration: clinicaltrials.gov Identifier: NCT00128388

The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Despite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors' knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder.This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18-55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure.Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results.Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.

OBJECTIVE The American Psychiatric Association (APA) practice guideline for panic disorder recommends psychodynamic psychotherapy for panic disorder patients with comorbid personality disorders. No data underlie this recommendation. This exploratory study assessed the moderating effect of personality disorder on psychodynamic and non-psychodynamic psychotherapy outcome. METHOD Forty-nine subjects with primary DSM-IV panic disorder were randomly assigned to 12 weeks of twice-weekly Panic-Focused Psychodynamic Psychotherapy or Applied Relaxation Training. The primary outcome measure was the Panic Disorder Severity Scale; the moderating effect of Axis II psychopathology on the Sheehan Disability Scale was also tested. The trial was conducted between February 2000 and January 2005. RESULTS Twenty-four subjects (49%) met DSM-IV criteria for a Structured Clinical Interview for DSM-IV Axis II Disorders-diagnosed personality disorder, of whom 19 (79%) had a cluster C diagnosis. Presence of a cluster C diagnosis moderated treatment outcome. Such subjects experienced greater improvements in Panic-Focused Psychodynamic Psychotherapy than subjects without cluster C comorbidity. CONCLUSIONS Despite its small sample size, this exploratory analysis provides initial preliminary evidence corroborating the APA practice guideline recommendation. Future panic disorder clinical trials should explore Axis II moderator effects. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov identifier NCT00128388.

Separation anxiety, long an area of interest for psychoanalysts, has been included in DSM-5 among general “anxiety disorders” that span across age groups. The syndrome of separation anxiety has been shown to correlate with nonresponse to treatments for anxiety and mood disorders (Milrod et al. 2014). It is therefore of public health importance to develop targeted treatments for this syndrome. Some psychoanalysts have suggested that brief psychoanalytic interventions may be of particular value in addressing separation anxiety. Our clinical work with patients with anxiety disorders with high levels of separation anxiety indicates that they have such intense anger and ambivalence in fraught intimate relationships that they feel stuck and helpless, almost eliminating more positive feelings. This ambivalence and associated unconscious conflicts inevitably emerge in the therapeutic relationship and can threaten to disrupt treatment efforts. We propose a set of focused psychodynamic psychotherapeutic interventions to address separation anxiety, developed as part of Panic-Focused Psychodynamic Psychotherapy–eXtended Range (PFPP-XR; Busch et al. 2012). We present a case from our research study of treatment nonresponders with anxiety disorders and separation anxiety. The patient was successfully treated with PFPP-XR in a 21-session treatment.

Clinically significant separation anxiety [SA] has been identified as being common among patients who do not respond to psychiatric interventions, regardless of intervention type (pharmacological or psychotherapeutic), across anxiety and mood disorders. An attachment formation and maintenance domain has been proposed as contributing to anxiety disorders. We therefore directly determined prevalence of SA in a population of adult treatment non-responders suffering from primary anxiety. In these separation anxious nonresponders, we pilot-tested an SA-focused, attachment-based psychotherapy for anxiety, Panic-Focused Psychodynamic Psychotherapy-eXtended Range [PFPP-XR], and assessed whether hypothesized biomarkers of attachment were engaged. We studied separation anxiety [SA] in 46 adults (ages 23–70 [mean 43.9 (14.9)]) with clinically significant anxiety symptoms (Hamilton Anxiety Rating Scale [HARS] ≥ 15), and reporting a history of past non-response to psychotherapy and/or medication treatments. Thirty-seven (80%) had clinically significant symptoms of separation anxiety (Structured Clinical Interview for Separation Anxiety Symptoms [SCI-SAS] score ≥8). Five of these subjects completed an open clinical trial of Panic Focused Psychodynamic Psychotherapy eXtended Range [PFPP-XR], a 21–24 session, 12-week manualized attachment-focused anxiolytic psychodynamic psychotherapy for anxiety. Patients improved on “adult threshold” SCI-SAS (current separation anxiety) (p = .016), HARS (p = 0.002), and global severity, assessed by the Clinical Global Impression Scale (p = .0006), at treatment termination. Salivary oxytocin levels decreased 67% after treatment (p = .12). There was no significant change in high or low frequency HRV after treatment, but change in high frequency HRV inversely correlated with treatment change in oxytocin (p < .02), and change in low frequency HRV was positively associated with change in oxytocin (p < .02). SA is surprisingly prevalent among non-responders to standard anti-anxiety treatments, and it may represent a novel transdiagnostic target for treatment intervention in this population. Anxiety and global function improved in a small trial of a brief, manualized, attachment-focused psychodynamic psychotherapy, potentially supporting the clinical relevance of attachment dysfunction in this sample. The large decrease in oxytocin levels with treatment, although not statistically significant in this very small sample, suggests the need for further study of oxytocin as a putative biomarker or mediator of SA response. These pilot data generate testable hypotheses supporting an attachment domain underlying treatment-resistant anxiety, and new treatment strategies.

This paper outlines the successful psychoanalytic treatment of a latency-aged boy with severe conversion disorder. Details of clinical treatment are presented. As no tested treatment has yet been found that reliably treats chronic conversion in children, this case is of importance in demonstrating the usefulness of psychoanalysis as treatment for severe psychopathology. The patient's unconscious fantasy constellations that gave rise to this syndrome are highlighted.

The psychoanalytic community increasingly recognizes the importance of research on psychoanalytic treatments, yet a significant number of psychoanalysts continue to believe that research is either irrelevant to psychoanalysis or impossible to accomplish. Psychoanalysts who accept the value of research express concern that intrusions required by research protocols create significant distortions in the psychoanalytic process. The authors, all psychoanalysts, are studying the outcome of a brief (twenty-four-session) psychodynamic treatment of panic disorder. They report their experiences and struggles with the intrusions of videotaping, working with a treatment manual, and time-limited treatment. This research process required them to question old beliefs and to confront feelings of disloyalty toward their analytic training and identity, particularly with regard to keeping a “clean field” and routinely performing long-term analysis of character. The therapists' psychoanalytic knowledge, however, emerged as crucial for them in managing specific research constraints. Despite concerns about providing inadequate treatment, therapists were found to engage patients with psychoanalytic tools and focus in vibrant and productive therapies that led to significant improvements in panic symptoms and associated quality of life. The authors suggest that psychoanalysts have been overestimating the potential damage of research constraints on psychoanalytic process and outcome.

Unconscious pregnancy fantasies are outlined as an underlying dynamic organizer to the panic experience in some patients with panic disorder. Detailed case material from the treatment of two childless panic patients, one male and one female (nonpregnant) is presented to illustrate this. A literature review found reports of nine nonpregnant patients, none exposed to a pregnant analyst, in whom these fantasies are described as central. Four of these patients had a psychiatric syndrome consistent with panic and agoraphobia. Some mechanisms that may underlie these connections are explored.

This article describes a course, Clinical Research in Psychotherapy, taught to PGY-3 residents at the New York Presbyterian Hospital-Weill Cornell Medical College. The course addresses existing research in outcome and process in psychotherapy, concepts important in research design, and assessment of results of psychotherapy research. It also explores how knowledge of research can enhance clinical practice. The authors believe that teaching psychotherapy research to residents will aid the development of a generation of clinicians who can best recognize the value of a psychodynamic approach for patients.

York, NY I 0021. lasted for 20 minutes and then gradually abated over the better part of an hour. Ms. A did not think of her panic as a reason for seeking psychiatric treatment. She did not have agoraphobia but lived with a chronic, vague sense of severe anxiety, accompanied by the fantasy that she was “doomed.” She had no specific phobias. The symptom that caused Ms. A the most distress was her chronic difficulty negotiat. ing relationships with others. Beginning with her earliest relationships with her parents and older sister in childhood, Ms. A found herself in interpersonal situations in which she felt abused and demeaned, either emotionally or physically. In high school and college she had often felt belittled by friends and boyfriends. Currently, these issues recurred in the context of her relationship with her fianc#{233} and her interactions with colleagues at graduate school. In the course of these stormy relationships, Ms. A would become so agitated and panicked that she was often violent. In the middle of fights with her fianc#{233}, for example, she would find herself hitting him and running out of the apartment dressed in insufficient clothing in the middle of the night. She had no vegetative symptoms. She had no history of depression, mania, psychosis, or substance abuse. She had never been suicidal. Ms. A’s medical history was considered noncontributory.

The case of a late adolescent with panic disorder and obsessivecompulsive disorder is described. The patient experienced resolution of both disorders in brief psychodynamic psychotherapy, but required psychoanalysis in order to make inroads into his restricted life-style. This case illustrates the continued usefulness of psychoanalysis in the treatment of such patients.

This manual presents a carefully researched, detailed psychodynamic treatment program for the alleviation of a transdiagnostic range of primary Axis I anxiety disorders, including panic disorder, generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, and related psychological problems. First exploring the principles of psychodynamic theory and formulation, the authors then present a three-phased process of Panic Focused Psychodynamic Psychotherapy-Extended Range (PFPP-XR): initial evaluation, interpretation of central conflicts and defense mechanisms, and termination. Each phase is discussed in depth and relies on central case illustrations to demonstrate techniques and results. A subsequent chapter explores how to address complex issues that may arise during the course of treatment. Altogether, this manual not only provides a demonstrated, adaptable approach for anxiety disorders, but also clearly embodies a spirit of research and empiricism heretofore rare in psychodynamic psychotherapies, with an eye toward future development.

Objective: The Ad Hoc Subcommittee for Evaluation of the Evidence Base for Psychodynamic Psychotherapy of the APA Committee on Research on Psychiatric Treatments developed the Randomized Controlled Trial Psychotherapy Quality Rating Scale (RCT-PQRS). The authors report results from application of the RCT-PQRS to 94 randomized controlled trials of psychodynamic psychotherapy published between 1974 and May 2010. Method: Five psychotherapy researchers from a range of therapeutic orientations rated a single published paper from each study. Results: The RCT-PQRS had good interrater reliability and internal consistency. The mean total quality score was 25.1 (SD=8.8). More recent studies had higher total quality scores. Sixty-three of 103 comparisons between psychodynamic psychotherapy and a nondynamic comparator were of "adequate" quality. Of 39 comparisons of a psychodynamic treatment and an "active" comparator, six showed dynamic treatment to be superior, five showed dynamic treatment to be inferior, and 28 showed no difference (few of which were powered for equivalence). Of 24 adequate comparisons of psychodynamic psychotherapy with an "inactive" comparator, 18 found dynamic treatment to be superior. Conclusions: Existing randomized controlled trials of psychodynamic psychotherapy are promising but mostly show superiority of psychodynamic psychotherapy to an inactive comparator. This would be sufficient to make psychodynamic psychotherapy an "empirically validated" treatment (per American Psychological Association Division 12 standards) only if further randomized controlled trials of adequate quality and sample size replicated findings of existing positive trials for specific disorders. We do not yet know what will emerge when other psychotherapies are subjected to this form of quality-based review.

OBJECTIVE: This report contains preliminary data from an open trial of brief psychodynamic psychotherapy for panic disorder. METHOD: Fourteen patients with primary DSM-IV panic disorder completed a 24-session, twice-weekly course of psychodynamic psychotherapy. Other psychiatric treatment was not permitted throughout the 12-week treatment period and the 6-month follow-up. Symptoms were assessed at baseline, treatment termination, and 6-month posttermination follow-up (40 weeks). RESULTS: Statistically significant, clinically meaningful improvements appeared in panic, depression, anxiety, and functional impairment both at treatment termination and at 6-month follow-up. CONCLUSIONS: Psychodynamic monotherapy can be used successfully to retain and treat patients with panic disorder. Psychodynamic interventions warrant further study for patients with panic disorder.

Context In 2004, the American Psychiatric Association's Committee on Research on Psychiatric Treatments appointed a subcommittee to investigate the status of empirical evidence with regard to psychodynamic psychotherapy. Objective As a part of this effort, the committee developed a rating scale designed to assess the quality of randomized controlled trials (RCTs) of psychotherapy. Data Sources A 25-item RCT of Psychotherapy Quality Rating Scale was generated by expert consensus. Interrater reliability, internal consistency, and validity testing were undertaken using 7 trained raters. Study Selection A PubMed search was conducted to locate all RCTs of psychotherapies identified by their authors as being "psychodynamic" or "psychoanalytic" in origin and implementation. Data Extraction A total of 69 RCTs were independently rated by 2 raters. Data Synthesis The scale was found to have good interrater reliability (total score intraclass correlation=0.76), internal consistency (Cronbach α = .87), and external validity. Conclusions This scale establishes a new standard for the design and execution of psychotherapy RCTs and provides a systematic empirical method for evaluating the quality of published RCTs.

In light of new research findings about the efficacy of psychodynamic treatment for panic disorder and agoraphobia, it seems a prudent time to carefully address psychoanalytic thinking about the treatment of agoraphobia. The literature has highlighted oedipal contributions to its genesis and clinical unraveling in psychoanalysis. While those contributions are indeed central to the disorder, structural deficits in the self-representation often become a central focus of treatment once symptomatic remission has been achieved in psychoanalytic treatment. This aspect of the clinical presentation of agoraphobia has not yet been specifically addressed in the psychiatric literature. Some aspects of the phenomenon have been described by psychoanalysts. It is more difficult to treat this “emptiness” than the overt symptoms of agoraphobia, as described in DSM-IV. Nonetheless, this phenomenon may be one of the contributors to the chronicity of the disorder. Two clinical cases illustrate these points.

Social anxiety disorder is a severe psychiatric syndrome that results in significant suffering and impairment in psychosocial function (1, 2) (this volume, chapter by Baldwin and Buis). Many theoretical models exist to describe the causes of this disorder. Although psychoanalysts have developed several theoretical models of the development of anxiety, they have rarely focused on specific anxiety disorders as described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (3). More systematic assessment of psychological factors and the development of therapeutic approaches to specific psychiatric syndromes has occurred only in recent years and remains outside mainstream psychoanalysis.